Friday, October 10, 2008

Diagnosing Pedophilia: Corrections

Issues for DSM-V: Unintended Consequences of Small Changes: The Case of Paraphilias

Although DSM-IV-TR includes many close judgment calls, it containsonly one outright mistake: in criterion A of the paraphiliasection. The unintended consequences following what we thoughtwas a small wording change provide a cautionary tale for DSM-V.The mistake arose from the decision to add the following criterionto most disorders in DSM-IV: "the disturbance causes clinicallysignificant distress or impairment in social, occupational,or other important areas of functioning." This was a reminderthat the symptom criteria alone are insufficient to define mentaldisorder. In the paraphilia section, the new wording replacedDSM-III-R criterion B, which had set the significance thresholdbased on either acting on the urges or experiencing distress. Furthermore, criterionA was amended (by adding "behavior" along with "fantasies" and"urges") to emphasize that it is behavior that most typicallybrings individuals to clinical attention.

The minor adjustment in criterion A caused more serious problems.The addition of "or behaviors" led some forensic evaluatorsto conclude that sexual offenders might qualify as having amental disorder based only on their having committed sexualoffenses (e.g., rape). In many states with sexually violentpredator statutes, the diagnosis of mental disorder is necessaryto trigger indefinite civil psychiatric commitment for sexuallyviolent offenders after their prison terms are completed. Theconstitutionality of these statutes hinges on the requirementthat the sexual offenses are caused by a "mental abnormality."Although the mental abnormality mentioned in the statutes isdefined by state legislature and is not equivalent to any DSMdisorder, the courts have acknowledged the importance of DSMdiagnoses in the determination of whether the statutorily definedmental health criteria are satisfied. The revised criterionA wording has sometimes been used to justify making a paraphiliadiagnosis based solely on a history of repeated acts of sexualviolence, which is then argued as satisfying the statutory mandatefor the presence of a "mental abnormality". This certainlywas never our intent in DSM-IV. Defining paraphilia based onacts alone blurs the distinction between mental disorder andordinary criminality. Decisions regarding possible lifelongpsychiatric commitment should not be made based on a misreadingof a poorly worded DSM-IV criterion item.

We regret the confusion caused and have two recommendations:1) although the contentious issue of sexually violent predatorcommitment cannot be resolved by a simple DSM wording change,we feel it is important to set the record straight and restorecriterion A to its DSM-III-R wording (i.e., remove the phrase"or behaviors") in DSM-V (if not sooner); 2) tinkering withcriteria wording should be done only with great care and whenthe advantages clearly outweigh the risks, both because of thepotentially unforeseen consequences of rewording criteria andbecause of the disruptive nature of all changes.